Insurers rely on doctors whose judgments have been criticized by courts

Legal and Incentive Structures

• ERISA’s lack of punitive damages means insurers risk only paying wrongly denied claims, not large penalties. Judges quoted in the article see this as enabling a “pay 10, avoid 1,000” incentive.
• Commenters argue this makes fraud or systematic bad-faith denial a rational business model.
• ACA’s medical loss ratio (≈80% of premiums must go to care/QI) is debated:
  • Some say it perversely incentivizes higher medical prices so insurers’ 20% cut grows.
  • Others counter that collusion and lax antitrust enforcement, not the MLR rule itself, are the core problem.

Role and Liability of Insurer-Employed Doctors

• Denial decisions by plan doctors are generally not treated as “practicing medicine,” so they’re shielded from malpractice suits.
• Many find this “odd,” arguing that determining “medical necessity” is inherently medical and should carry liability.
• Opposing view: these doctors only influence payment, not whether care can be provided (patient could pay cash, clinician could donate care), so malpractice rules don’t neatly apply.
• Deep concern over conflicts of interest: doctors are paid by entities that profit when care is denied; some liken this to criminal negligence or even intentional harm.

Costs, Profit Motives, and Claim Denials

• Broad agreement that denials are about cost control, not just fraud prevention.
• Dispute over where main cost drivers lie:
  • Some blame insurers’ perverse incentives and administrative friction.
  • Others point to hospitals and pharma as higher-margin, larger cost components.
• Several note massive provider time spent on coding, prior auth, appeals, and billing.

Systemic Barriers to Reform in the U.S.

• Many see the system as a “Moloch”-like equilibrium: every subsystem is defended by its beneficiaries; changing the whole triggers unified resistance.
• Lobbying, legal corporate political spending, and the sector’s share of GDP make structural reform extremely hard.
• Ideological factors: anti-“socialism,” racism, and “rugged individualism” lead many voters to resist paying for others’ care, even while they already cross-subsidize via premiums and taxes.
• Some argue the U.S. is effectively an oligarchy where majority support for reform does not translate into policy.

International Comparisons and Single-Payer Debates

• Non-U.S. commenters contrast U.S. costs and outcomes with European systems (e.g., Denmark, NZ, UK), asking why the U.S. doesn’t adopt single payer.
• Pro–single-payer arguments: lower overall costs, universal coverage, better bargaining power on drugs and procedures, less administrative overhead.
• Skeptical points:
  • Single-payer may mean longer waits and less access to newest treatments; some cite Canada/UK wait-time issues.
  • Others reply that U.S. patients without money or strong insurance already face long waits or non-treatment.
• Consensus that some form of rationing is unavoidable in any system; disagreement is over whether rationing should be by price, queue, medical criteria, or bureaucracy.

Capacity, Provider Supply, and Training

• Several identify constrained capacity—especially physicians, certain specialists, and imaging—as a root cause of high costs and waits.
• U.S. residency slots are federally capped, creating a bottleneck; there is debate on who should fund expansion (federal govt vs hospitals vs patients via higher bills).
• Suggested remedies: train more providers, expand nurse practitioner/PA roles, and remove barriers like certificate-of-need laws. Others warn such “efficiencies” can just be used to degrade care quality further.

Administrative Complexity and Transparency

• Commenters ask why insurers can’t provide upfront, precise cost estimates via apps.
  • Responses: coding is uncertain until after procedures; providers and payers have fragmented, opaque systems.
• Some note existing price-transparency tools and mandates, but enforcement is weak and code differences make them hard to use.
• There is broad frustration that U.S. healthcare prices are uniquely opaque, with “list prices” used as leverage in negotiations and to overcharge the uninsured.

Frustration and Radicalization

• Many express deep cynicism that policy tweaks or protests will fix a system protected by money and law.
• One commenter explicitly endorses violent retaliation against industry leaders, reflecting extreme despair; others focus instead on legal reforms (e.g., RICO, changing ERISA, malpractice exposure for insurer doctors).